Troop and Service Unit Activity Approval Form v2

Troop and Trip Information

Your Name

First NameLast Name

Your Volunteer Role

Your Phone Number

Area CodePhone Number

Your Alternate Phone Number

Area CodePhone Number

Your Email

example@example.com

Service Unit

Troop Number

What type of activity?

Name of Destination

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If visiting multiple cities, please list all locations you plan to visit.

Activity Start Date

Date

Activity End Date

Date

What is the grade level of the youngest Girl Scout participating?

Select the activities that best fit what you will be doing: (Daisies)

Select the activities that best fit what you will be doing: (Brownies)

Select the activities that best fit what you will be doing: (Juniors)

Select the activities that best fit what you will be doing: (Cadettes)

Select the activities that best fit what you will be doing: (Seniors)

Select the activities that best fit what you will be doing: (Ambassadors)

Include additional comments if needed.

What is the farthest distance the group will be traveling?

How many Girl Scout members from each program grade level will be participating? Please use their level at the time of the activity.

Adult-in-Charge on Trip

First NameLast Name

Adult-in-Charge Phone Number

Area CodePhone Number

Adult-in-Charge Alternate Phone Number

Area CodePhone Number

Adult-in-Charge Email

example@example.com

How many current Girl Scout volunteers will be attending? For all activities, there must be at least 2 unrelated volunteers, one of whom is female. More volunteers may be needed, depending on specific activity and girls' grade levels. (Review current Safety Activity Checkpoints for safety ratio.)

Names of all adult volunteers attending (all adults attending an overnight trip must be a background checked volunteer)

How many other adult Girl Scout members will be attending?

How many non-Girl Scout member adults will be attending?

Will there be any non-Girl Scout youth members participating?

Please list the number of non-Girl Scout youth members participating:

Emergency Contact Name (not attending activity)

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

Emergency Contact Alternate Phone Number

Area CodePhone Number

Emergency Contact Email

example@example.com

Adult Training/Certificate Checklist*

*Depending on the type of activity, certification/training may not be applicable.

First Aid/CPR

Other Training/Certification Held (if needed for activity)

Acknowledgements (Click "Yes" or "No" for the following statements):

Rows	Yes	No
*I understand that if this activity will result in earning money for the troop or service unit, I may also be required to submit an application for money earning and will take steps to do so.
*All standards and guidelines as stated in Volunteer Essentials and Safety Activity Checkpoints will be adhered to.
*Parental Permission Activity Forms must be received from all girl participants and Health History and Emergency Medical Authorization forms must be received from all participants.
*Appropriate youth/volunteer ratios will be met.
*GSCSA Emergency Procedures will be followed.
*All participating adults will have the phone numbers of the Council Office (800-474-1912) and in case of emergency call 911.

Volunteer Agreement

I, and all adult volunteers participating in this trip/activity, have reviewed all of the policies, procedures, and guidelines of the Girl Scouts of the Southern Appalachians and GSUSA as stated in Volunteer Essentials and the Safety Activity Checkpoints and agree to follow them.

I understand that a minimum of 10 business days is required for submission of this form.

Signature

Date Form Submitted